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Principles of Biomedical Ethics
EIGHTH EDITION
Tom L. Beauchamp
James F. Childress
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PREFACE TO THE EIGHTH EDITION
Biomedical ethics, or bioethics, was a youthful field when the first edition of this book went to press in late
1977, now over forty years ago. The word bioethics was a recently coined term when, in the mid-1970s, we
began as a team writing in this field and lecturing to health professionals on the subject of moral theory and
principles. The field had virtually no literature that engaged moral theory and methodology. Massive changes
have since occurred both in the field and in this book. We have tried to stay as close to the frontiers of this field
as we could, even though the literature is now sufficiently extensive and rapidly expanding that it is difficult to
keep abreast of new topics under discussion.
For those who have stayed with us through the previous editions of Principles of Biomedical Ethics, we express
our gratitude for your critical and constructive suggestions—for us a constant source of information and insight,
as well as inspiration. Substantial changes have appeared in all editions after the first, and this eighth and
perhaps final edition is no exception. No new changes have been made in the book’s basic structure, but the
revisions are thoroughgoing in every chapter. We have attempted to sharpen our investigations, strengthen our
arguments, address issues raised by critics, and both reference and assess new published material. As in previous
editions, we have made changes in virtually every section and subsection of the book’s ten chapters.
Our clarifications, additions, expansions, and responses to critics can be crisply summarized as follows:
Part I, Moral Foundations: In Chapter 1, “Moral Norms,” we have clarified, augmented, and tightened our
accounts of the common morality, universal morality, and how they differ from particular moralities. We have
also clarified in this chapter and Chapter 10 the ways in which the four-principles framework is to be understood
as a substantive framework of practical normative principles and a method of bioethics. We have had a major
commitment to the virtues and moral character since our first edition. In Chapters 2 and 9 we have clarified and
modestly expanded our discussion of the nature and importance of moral virtues, moral ideals, and moral
excellence; and we have also revised our account of the lines that separate what is obligatory, what is beyond
obligation, and what is virtuous. In Chapter 3, “Moral Status,” we have revised our account of theories of moral
status in several ways and revised our presentation in the section on “Guidelines Governing Moral Status:
Putting Specification to Work.” We also engage some moral problems that have emerged about the use of
human-nonhuman chimeras in biomedical research. We there concentrate on whether functional integration of
human neural cells in a nonhuman primate brain (and the brains of other species) would cause a morally
significant change in the mind of the animal, and, if it did so, what the consequences should be for the moral
status of the animal if it were born.
Part II, Moral Principles: The principles of basic importance for biomedical ethics are treated individually in
Part II. In Chapter 4, “Respect for Autonomy,” we have expanded our presentations in several sections including
addition of an analysis of the distinction between the justification of informed consent requirements and the
several functions served by the doctrine, institutions, and practices of informed consent. Also added is a
significant clarification of our theory of intentional nondisclosure in clinical practice and research and the
conditions under which intentional nondisclosure is justified. In Chapter 5, “Nonmaleficence,” we have updated
and deepened our constructive proposals about “Distinctions and Rules Governing Nontreatment,” proper and
improper uses of the best-interest standard, and the place of anticipated quality of life in decisions regarding
seriously ill newborns and children. The sections on decisions about physician-assisted dying are updated and
arguments adjusted in light of global developments, especially in North America (Canada and several US states).
In Chapter 6, “Beneficence,” we deepened our analysis of policies of expanded and continued access to
investigational products in research as well as our discussions of the ethical value of, concerns about, and
constraints on risk-benefit, cost-benefit, and cost-effectiveness analyses. In Chapter 7, “Justice,” we updated and
expanded the discussions of theories of justice, with restructured presentations of communitarian theories,
capability theories, and well-being theories. Also updated are sections on problems of health insurance coverage,
social implementation of the right to health care, and the right to a decent minimum of health care—as well as
revised analyses of whether individuals forfeit this right through risky actions and what the fair opportunity rule
requires by way of rectifying disparities in health care. Chapter 8, “Professional-Patient Relationships,” has
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expanded sections on “Veracity” and “Confidentiality,” each of which incorporates new cases. The section on
arguments for intentionally limiting communication of bad news has been updated. In particular, we have
deepened our account of when physicians’ decisions to use staged disclosures are ethically justified.
Part III, Theory and Method: Chapter 9, “Moral Theories,” has an expanded section on “Virtue Theory” that fills
out our account of the virtues introduced in Chapter 2 and furthers the application of our theory to biomedical
ethics. We have also augmented and clarified the section on rights theory. Significant additions appear in the
section on “The Rights of Incompetent, Disadvantaged, and Unidentified Members of Populations.” In Chapter
10, “Method and Moral Justification,” we have strengthened our critiques of theories of justification in what we
call top-down models and casuistry. We have also expanded our accounts of common-morality theory, moral
change, reflective equilibrium, considered judgments, and the ways in which our theory is committed to a global
bioethics. Each of these parts has been recast to clarify and deepen our positions.
Finally, we want to correct some long-standing misinterpretations of our theory that have persisted over the forty
years of editions of this book. Several critics have maintained that our book is committed to an American
individualism in which the principle of respect for autonomy dominates all other moral principles and
considerations. This interpretation of our book is profoundly mistaken. In a properly structured account of
biomedical ethics, respect for autonomy has no distinctly American grounding and is not excessively
individualistic or overriding. We do not emphasize individual rights to the neglect or exclusion of social
responsibilities and communal goals. We do not now, and have never, treated the principle of respect for
autonomy in the ways several of our critics allege. To the contrary, we have always argued that many competing
moral considerations validly override this principle under certain conditions. Examples include the following: If
our choices endanger public health, potentially harm innocent others, or require a scarce and unfunded resource,
exercises of autonomy can justifiably be restricted by moral and legal considerations. The principle of respect
for autonomy does not by itself determine what, on balance, a person ought to be free to do or what counts as a
valid justification for constraining autonomy.
Our position is that it is a mistake in biomedical ethics to assign priority a priori to any basic principle over other
basic principles—as if morality is hierarchically structured or as if we must value one moral norm over another
without consideration of particular circumstances. The best strategy is to appreciate the contributions and the
limits of various principles, virtues, and rights, which is the strategy we have embraced since the first edition and
continue throughout this edition. A number of our critics have mistakenly maintained—without textual warrant
—that our so-called principlism overlooks or even discounts the virtues. We have given a prominent place in our
theory—since the first edition—to the virtues and their significant role in biomedical ethics. We maintain and
further develop this commitment in the present edition.
Fortunately, we have always had a number of valuable—and often constructive—critics of our theories,
especially John Arras, Edmund Pellegrino, Raanan Gillon, Al Jonsen, Stephen Toulmin, Michael Yesley,
Franklin Miller, David DeGrazia, Ronald Lindsay, Carson Strong, John-Stewart Gordon, Oliver Rauprich,
Jochen Vollmann, Rebecca Kukla, Henry Richardson, Peter Herissone-Kelly, Robert Baker, Robert Veatch, Tris
Engelhardt, Robert “Skip” Nelson, and Neal W. Dickert. Our book owes a great deal to these critics and friends.
We again wish to remember with great fondness and appreciation the late Dan Clouser, a wise man who seems
to have been our first—and certainly one of our sternest—critics. We also acknowledge the penetrating
criticisms of Clouser’s friend, and ours, the late Bernard Gert, whose trenchant criticisms showed us the need for
clarifications or modifications in our views. We also thank John Rawls for a lengthy conversation, shortly before
his untimely death in 2002, about communitarian and egalitarian theories of justice that led to significant
improvements in our chapter on justice.
We have continued to receive many helpful suggestions for improvements in our work from students,
colleagues, health professionals, and teachers who use the book. Jim is particularly grateful to his University of
Virginia colleagues: the late John Arras, already mentioned; Ruth Gaare Bernheim; Richard Bonnie; and the late
John Fletcher for many illuminating discussions in team-taught courses and in other contexts. Discussions with
many practicing physicians and nurses in the University of Virginia’s Medical Center, on its Ethics Committee,
and with faculty in the Center for Biomedical Ethics and Humanities have been very helpful. In addition, Jim
thanks the faculty and graduate students of the Centre for the Advanced Study of Bioethics at the University of
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Münster for gracious hospitality and vigorous and valuable conversation and debate, particularly about
paternalism and autonomy, especially during extended visits in 2011 and 2016; Bettina Schöne-Seifert, Thomas
Gutmann, and Michael Quante deserve special thanks. Jim also expresses his deep gratitude to Marcia Day
Childress, his wife for the last twenty-two years, for many valuable suggestions along with loving and unstinting
support throughout the preparation of the eighth edition as well as the preceding three editions.
Tom likewise wishes to thank his many colleagues in Georgetown University’s Philosophy Department and
Kennedy Institute of Ethics, as well as his colleagues in research at the Berman Institute of Bioethics of The
Johns Hopkins University. Henry Richardson and Rebecca Kukla have been penetrating, as well as constructive,
critics from whom several editions of this book have greatly benefited. Between the sixth and seventh editions,
Tom benefited hugely from his work with colleagues at Johns Hopkins on an NIH grant to study the need to
revise our understanding of the research–practice distinction: Ruth Faden, Nancy Kass, Peter Pronovost, Steven
Goodman, and Sean Tunis. When one has colleagues this talented and well informed, multidisciplinary work is
as invigorating as it is instructive.
Tom also wishes to express appreciation to five undergraduate research assistants: Patrick Connolly, Stacylyn
Dewey, Traviss Cassidy, Kekenus Sidik, and Patrick Gordon. Their research in the literature, their editing of
copy, and their help with previous indexes have made this book more comprehensive and readable. Likewise,
Jim wishes to thank three superb research and teaching assistants, Matt Puffer, Travis Pickell, and Laura
Alexander, for their helpful contributions. Other teaching assistants in a lecture course at the University of
Virginia that used this book also made valuable suggestions.
We also acknowledge with due appreciation the support provided by the Kennedy Institute’s library and
information retrieval systems, which kept us in touch with new literature and reduced the burdens of library
research. We owe a special debt of gratitude to Martina Darragh, who retired as the last chapter of this eighth
edition was being completed. Martina gave us help when we thought no help could be found.
Retrospectively, we express our gratitude to Jeffrey House, our editor at Oxford University Press for the first
thirty years of this book. Jeff encouraged us to write it before a single page was written, believed in it deeply,
and saw it through all of its formative editions. He was an emulable editor. We also thank Robert Miller for
efficiently facilitating the production of the recent editions of this book.
We dedicate this edition, just as we have dedicated each of the previous seven editions, to Georgia, Ruth, and
Don. Georgia, Jim’s beloved wife of thirty-five years, died in 1994, just after the fourth edition appeared. Our
dedication honors her wonderful memory and her steadfast support for this project from its inception. Tom also
acknowledges the love, devotion, and intellectual contribution to this book of his wife, Ruth Faden, who has
been the deepest influence on his career in bioethics, and salutes Donald Seldin, a brilliant physician and an
inspiration to Tom and to biomedical ethics since the early years of the field. Don passed away at age ninety-
seven in 2018, when we were in the midst of preparing this eighth edition. He will be sorely missed, and never
forgotten.
Washington, DC, and Chilmark, MA T.L.B.
Charlottesville, VA J.F.C.
January 2019
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